|Year : 2013 | Volume
| Issue : 1 | Page : 5-6
Nonclosure of rectourethral fistula during posterior sagittal anorectoplasty: Our experience
Sudhakar Jadhav, Amit Raut, Jui Mandke, Santosh Patil, Ravindra Vora, Dinesh Kittur
SJKC Trust's Paed-Surgery Centre and P.G Institute, Sangli, Maharastra, India
|Date of Web Publication||7-Feb-2013|
SJKC Trust's Paed-Surgery Centre and P.G Institute, Opp. DSP office, Vishrambag, Sangli, Maharastra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: To study the effect of nonclosure of rectourethral (RU) fistula and to do a comparative analysis of the complications with and without nonclosure of RU fistula during posterior sagittal anorectoplasty (PSARP) in anorectal malformation cases (ARM). Materials and Methods: A total of 68 cases of ARM were included in the study group, of which 34 cases were those in whom RU fistula was not closed (group A) during PSARP. Another 34 successive cases were included in study group B in whom the RU fistula was closed as is conventionally done by using interrupted sutures. Results: Comparatively, group A had none or minimum urological complications as compared to Group B. Conclusion: RU fistula closure is not mandatory during PSARP and nonclosure avoids urological complications. It especially avoids urethral complications, which are 100% preventable.
Keywords: Anorectal malformation, rectourethral fistula, urologic injury
|How to cite this article:|
Jadhav S, Raut A, Mandke J, Patil S, Vora R, Kittur D. Nonclosure of rectourethral fistula during posterior sagittal anorectoplasty: Our experience. J Indian Assoc Pediatr Surg 2013;18:5-6
|How to cite this URL:|
Jadhav S, Raut A, Mandke J, Patil S, Vora R, Kittur D. Nonclosure of rectourethral fistula during posterior sagittal anorectoplasty: Our experience. J Indian Assoc Pediatr Surg [serial online] 2013 [cited 2020 May 30];18:5-6. Available from: http://www.jiaps.com/text.asp?2013/18/1/5/107004
| Introduction|| |
Repair of anorectal malformation (ARM) with rectourethral (RU) fistula involves the separation of two systems. This involves risk of injury to the urethra, ureters, seminal vesicles, bladder, and important nerves responsible for urinary control and sexual function.
| Materials and Methods|| |
Group A included patients of ARM with RU fistula who had undergone posterior sagittal anorectoplasty (PSARP) without closure of RU fistula, from February 2006 to January 2010. The rest of the PSARP procedure was the same as conventionally done, the only difference being that we did not close the RU fistula after separating it from the rectum. We just separated the rectum from the urethra and left the urethral fistula as it is without closing it. We did not close the RU fistula using interrupted sutures as is conventionally done. Group B included 34 previous successive patients who had undergone PSARP before January 2006 in whom the RU fistula was closed using interrupted sutures. All the patients in both the groups had undergone staged repair of ARM and not primary PSARP. Micturating cystourethrogram (MCU) and distal colostogram was done in all these patients prior to PSARP.
All the patients were evaluated during follow-up both clinically and with investigations like MCU and cystoscopy. The patients were studied for parameters like urinary stream, urinary dribbling, urinary tract infections, and recurrent RU fistula. All patients had undergone preoperative and postoperative MCU three months after PSARP. Moreover, all patients had undergone urethrocystoscopy three months after PSARP to check for the status of the urethra and bladder. Patients who had sacral agenesis were excluded from the study group because such congenital sacral defects can lead to a neurogenic bladder. Perurethral catheter was removed on sixth postoperative day.
| Results|| |
The following were the observations in group A (a) In the immediate postoperative period, there was no urinary leakage, urinary retention, or any other complication; thus all these patients had an uneventful recovery. (b) Urinary stream was normal; there was no evidence of urinary dribbling or retention, urinary tract infection, and recurrent rectourinary fistula during follow-up. MCU showed normal urethra, without any evidence of stenosis or stricture, urethro-ejaculatory duct/vasal reflux, or diverticulum in any of the cases. Urethrocystoscopy also showed a normally healed urethra.
However, in Group B, complications like urethral stenosis, urethral diverticulum, and neurogenic dysfunction were seen. A comparative analysis of the two groups was done and overall complications were listed [Table 1].
| Discussion|| |
During PSARP, urological injuries in male patients are known complications. ,, Excessive traction on the urethra during dissection leads to transection or injury to the urethra. It is extremely important for the surgeon to bear in mind that in ARM with RU fistula, the rectum is intimately attached to the urethra and that meticulous dissection and separation are necessary. Urethral stenosis can occur due to traction on the RU fistula, that is, indirect traction on the urethra during separation and closure of fistula. Urethral stenosis can be avoided by applying less traction on the fistula during separation and avoiding the closure of fistula; we have seen in our series that urethral stenosis was not seen in any of the cases of group A, where the RU fistula was not closed. Closing the fistula using interrupted sutures can increase the chances of urethral stenosis or stricture. Another point to note is that if we separate the rectum from the urethra very near the urethral wall and use interrupted sutures for its closure, it also increases the chances for urethral stenosis. Thus the nonclosure of the fistula avoids urethral stenosis. Urethral stenosis due to ligation or closure of the RU fistula may result in recurrent epididymo-orchitis. 
Urethral diverticulum is the result of a segment of the rectum left attached to the urethra and the separated end closed. Such patients usually present with recurrent urinary tract infections, stone formations in diverticulum again leading to dysuria, urinary tract infections, and so on. , This complication can be avoided by separating the rectum away from the urethra without leaving any segment of the rectum attached and leaving the fistula as it is without closing it, so that nothing like a pouch/diverticulum is formed.
Neurogenic dysfunction after PSARP has been reported in the form of neurogenic bladder, , impotence, or loss of ejaculation.  Postoperatively, a neurogenic bladder may reflect a poor surgical technique with denervation of bladder and bladder neck during repair. , By avoiding the closure of the RU fistula, we can avoid excessive traction on the fistula and hence on the urethra, and also prevent the excessive dissection during fistula closure and minimize the chance of neurogenic dysfunction. Damage to the external vesical sphincter has also been reported during ligation or closure of the fistula.  Thus by avoiding closure of the fistula, we avoid this complication also and, hence, neurovesical dysfunction. Thus we have seen that by not doing something, that is, by not closing the RU fistula during PSARP, we can avoid many complications; so, not doing something is preferable here.
| Conclusion|| |
It is not mandatory to close the RU fistula during PSARP. Moreover, nonclosure of the RU fistula avoids urological complications, especially urethral complications.
| References|| |
|1.||Pena A, Levitt MA. Anorectal malformations. In: Grosfeld JL, editor. Pediatric surgery. 6 th ed. Mosby Elsevier, Philadelphia 2006. p. 1586. |
|2.||Spence HM. Anomalies and complications of urogenital tract associated with congenital imperforate anus. J Urol 1954;71:453-63. |
|3.||Tank ES, Erns CB. Urinary tract complications of anorectal surgery. Am J Surg 1972;123:118-22. |
|4.||Oðuzkurt P, Tanyel FC, Büyükpamukçu N. Acute scrotum due to epididymo-orchitis in children with ARM. J Pediatr Surg 1998;33:1834-6. |
|5.||Persky L, Tucker A. Urological complications of correction of imperforate anus. J Urol 1974;111:415-8. |
|6.||Nakayama DK, Tempelton JM Jr, Ziegler MM, O'Neill JA, Walker AB. Complications of posterior sagittal anorectoplasty. J Pediatr Surg 1982;21:488-92. |
|7.||Hong AR, Acuna MF, Peña A, Chaves L, Rodriguez G. Urological injuries associated with repair of ARM in male patients. J Pediatr Surg 2002;37:339-44. |
|8.||Kilic N, Emir H, Sander S, Eliçevik M, Celayir S, Söylet Y. Comparison of urodynamic investigations before and after posterior sagittal anorectoplasty for anorectal malformations. J Paediatr Surg 1997;32:1724-7. |